Public Health England is responsible for quality assurance of several NHS screening programmes. This document discusses recurring incident themes and lessons learned from sickle cell and thalassemia screening, fetal anomaly screening, infectious disease screening, newborn bloodspot screening, and newborn and infant physical examination screening. Common issues included missed or delayed screening due to failure to identify cohorts, lack of follow up procedures, and errors in screening processes and IT systems. The document emphasizes using standardized incident reporting forms, communicating between departments, and learning from past issues to strengthen screening programmes.

1. Public Health England is responsible for the NHS Screening Programmes
Quality Assurance (London)
Incidents
Themes & Shared Learning
Michelle Onslow, Senior QA Advisor

2. Sickle Cell and Thalassaemia
• Incidents often identified via NBS screening
• Unexpected affected babies:
needs to be clear that Screening is for common
mutations only
Screening not diagnosis
Some rare mutations may not be detected
• Missed or Delayed Screening:
Failure to identify the cohort
Not following up DNA’s
2 Incident - themes & shared learning

3. Sickle Cell and Thalassaemia
• Failure to follow up on father results and/or link
results and recognise high risk couples
• Not offering PND when the father is not available
for testing
• Failure to enter care both women and newborns
• Incorrect information on FOQ resulting in an
incorrect report/action required
3 Incident - themes & shared learning

4. FASP
• Missed/delayed Screening:
Failure to identify cohort
Lack of failsafe’s – with lab and internally
Failure to follow up DNA
• Failure to complete second trimester screening
for women who have a failed NT or who are too
late for first Trimester screening
• Incorrect data on request form = incorrect risk
calculation
4 Incident - themes & shared learning

5. FASP
• Delay or failure in following up screen positive
results – too late for PND
• Undiagnosed fetal anomaly at birth:
 Not necessarily an incident if correct pathway was
followed
 Not 100% detection rate, screening not diagnosis
 Should be reported to provide assurance that the
correct pathway has been followed
5 Incident - themes & shared learning

6. Infectious Diseases
• Missed/delayed Screening:
Failure to identify cohort
Lack of failsafe’s – with lab and internally
• Failure to administer HBIG:
 Lack of robust processes in place, ordering, storage,
administration
 Decision made by clinician due to <HBV DNA Viral
load
 National statement released – HBIG should be given
if ANY HBV DNA in pregnancy is high
 HBIG and vaccine on midwives exemptions
6 Incident - themes & shared learning

7. Infectious Diseases
• Failure to follow up screen positive results:
 Delayed entry into care
 Delayed treatment and/or missed intervention
 Relying on fax of results
 Lack of contingency when staff absent
 Failure to follow up DNA
7 Incident - themes & shared learning

8. NHSP
• Errors associated with implementation of a new
maternity IT system
 Upload of birth notification
 Information sent to the wrong site
• Delay in screening due to incorrect information
entered i.e. deceased when live birth
• Failure to notify of stillbirth or neonatal death
resulting in inappropriate contact with a family
• Screening by an screener who has not
completed qualification
8 Incident - themes & shared learning

9. Newborn Bloodspot
• Largest number of incidents reported of all the
programmes
• Delayed/missed screening:
Failure of discharge information being received by
correct Trust – still relying on fax
Lack of timely transfer of babies that move - Northgate
‘disagreements’ over who has responsibility
Failure to screen ‘movers in’
Delays in independent midwives repeating samples
Units with high NB2 rates have highest number of
incidents
9 Incident - themes & shared learning

10. NIPE
• Delayed/missed screening:
 Failure to identify cohort –
 Sites with SMART not utilising system as a failsafe
 Failure to identify ‘outliers’ i.e. babies in HDU with
mother etc.
• Failure/delay in entering care:
 No referral done
 Referral not followed up
 DNA not followed up
10 Incident - themes & shared learning

11. General
• New screening incident assessment form:
 Please ensure that this is used to report all incidents
and not the old ‘early alert’ form
• Errors on maternity IT system:
Lack of understanding that once the information has
been ‘submitted’ amending on the maternity system is
not sufficient
SOP recommended
Look for evidence of this at QA visit
11 Incident - themes & shared learning

12. General
• If patient identifiable information is lost:
 For example an NBS sample is taken and sent to the
lab but never arrives
 This is not always a screening incident but it is an
information governance breach and the Trust IG team
should be informed
• Don’t forget to consider your Trust
communications department:
 Essential if women are being contacted and/or
recalled
 They are likely to want to review letters etc. before
they are sent
12 Incident - themes & shared learning